Parents' Reports of Barriers to Care for Children With Special Health Care Needs: Development and Validation of the Barriers to Care Questionnaire

Barriers to healthcare access for children with congenital heart disease in eight Latin American countries

BACKGROUND

Mortality from congenital heart disease has decreased considerably in the last two decades due to improvements in overall health care. However, there are barriers to access to healthcare in Latin America for this population, which could be related to factors such as healthcare system, policies, resources, geographic, cultural, educational, and psychological factors. Understanding the barriers to access to care is of paramount importance for the design and implementation of policies and facilitate the provision of care.

AIM

The aim of the study was to investigate the perception of barriers to access to health care on parents/guardians of children with congenital heart disease in selected Latin American countries.

METHODS

A descriptive, cross-sectional study, in which parents/guardians or primary caregivers of children with congenital heart disease was recruited to participate and surveyed. Once the informed consent process had been completed, a set of paper-based scales was used to collect data, namely socioeconomic and demographic information, the Barriers to Care for Children with Special Health Care Needs Questionnaire, and the General Health Questionnaire.

RESULTS

In total, 286 participants completed the surveys, with an average age of 34.81 years and 73.4% being female. Mean score of overall barriers was 54.45 (minimum score 39, maximum score 195, higher scores show greater perception of barriers). In Mexico, the parents/guardians of children perceived fewer barriers to access (46.69), while Peru is the country where the most barriers were perceived (69.91). Nonpoor participants showed higher overall barrier perception scores (57.34) than poor participants (52.58). The regression analysis demonstrated the overall perception of barriers was positively associated with individual and social factors, such as educational level, contract status, household monthly income, and psychological well-being and with the country of the participants.

CONCLUSIONS

Multiple factors are associated with the perception of barriers to accessing health care for children with congenital heart disease, including socioeconomic status, expectations, psychological well-being, and structural factors.

Factors Impacting Follow-Up Care in Allergic Fungal Rhinosinusitis

OBJECTIVE

The purpose of this study was to analyze barriers to medical care and follow-up in patients with allergic fungal rhinosinusitis (AFRS).

STUDY DESIGN

Cross-sectional questionnaire-based study with retrospective chart review.

SETTING

Tertiary Medical Center.

METHODS

Subjects with AFRS and chronic rhinosinusitis with nasal polyps (CRSwNP) were prospectively recruited for completion of the Barriers to Care Questionnaire (BCQ) and formal chart review.

RESULTS

Fifty-nine AFRS and 51 CRSwNP patients participated. AFRS patients were more likely to be lost to follow-up within 6 months of surgery (35.6% vs 17.7%, P = 0.04) and no-show at least 1 appointment (20.3% vs 5.9%, P = 0.03) compared to CRSwNP patients. Men with AFRS were more likely to have only a single follow-up visit (37.0% vs 3.1%, P < 0.001) and be lost to follow-up (66.7% vs 9.4%, P < 0.001) than women. There were no significant differences in the BCQ between groups; however, rate of questionnaire completion was lower in the AFRS group than the CRS group (62.7% vs 80.4%, P = 0.042). AFRS patients who did not complete the BCQ were more likely to be male (63.6% vs 35.1%, P = 0.034), lost to follow-up (77.3% vs 10.8%, P < 0.0001), and have a single follow-up visit (40.9% vs 5.4%, P < 0.0001). Younger age was associated with increased likelihood of having a single follow-up visit (odds ratio 1.143, 95% CI 1.022-1.276).

CONCLUSION

Young, male AFRS patients are more frequently lost to follow-up after surgery and less likely to complete questionnaires assessing barriers to care. Further investigation is needed to assess barriers to follow-up in these at-risk groups.

Identifying barriers and facilitators to care for infants with bronchopulmonary dysplasia after NICU discharge: a prospective study of parents and clinical stakeholders

OBJECTIVE

Understand barriers and facilitators to follow-up care for infants with bronchopulmonary dysplasia (BPD).

METHODS

Qualitative study of parents and clinical stakeholders caring for infants with BPD. The interview guide was developed by a mother of a former 23-week preterm infant, neonatologist, pulmonologist, nurse, and qualitative researcher. Purposive sampling obtained a heterogenous sociodemographic and professional cohort. Subjects discussed their experience with BPD, barriers to care, caregiver quality of life and health education. Interviews were audio-recorded, transcribed and coded. Thematic analysis was used.

RESULTS

Eighteen parents and 20 stakeholders completed interviews. Family-level themes included pragmatic barriers like transportation being multi-faceted; and caregiving demands straining mental health. System-level themes included caregiver education needing to balance immediate caregiving activities with future health outcomes; and integrating primary care, specialty, and community supports.

CONCLUSIONS

Individual and system barriers impact follow-up for infants with BPD. This conceptual framework can be used to measure and improve care.

Pilot Evaluation of the Family Bridge Program: A Communication- and Culture-Focused Inpatient Patient Navigation Program

OBJECTIVE

Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program.

METHODS

Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests.

RESULTS

Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received >2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100).

CONCLUSIONS

The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities.

Understanding constraints to adaptation using a community-centred toolkit

Worldwide, marginalized and low-income communities will disproportionately suffer climate change impacts while also retaining the least political power to mitigate their consequences. To adapt to environmental shocks, communities must balance intensifying natural resource consumption with the need to ensure the sustainability of ecosystem provisioning services. Thus, scientists have long been providing policy recommendations that seek to balance humanitarian needs with the best outcomes for the conservation of ecosystems and wildlife. However, many conservation and development practitioners from biological backgrounds receive minimal training in either social research methods or participatory project design. Without a clear understanding of the sociocultural factors shaping decision-making, their initiatives may fail to meet their goals, even when communities support proposed initiatives. This paper explores the underlying assumptions of a community's agency, or its ability to develop and enact preferred resilience-enhancing adaptations. We present a context-adaptable toolkit to assess community agency, identify barriers to adaptation, and survey perceptions of behaviour change around natural resource conservation and alternative food acquisition strategies. This tool draws on public health and ecology methods to facilitate conversations between community members, practitioners and scientists. We then provide insights from the toolkit's collaborative development and pilot testing with Vezo fishing communities in southwestern Madagascar. This article is part of the theme issue 'Climate change adaptation needs a science of culture'.

Identifying Barriers and Facilitators to Care for Infants with Bronchopulmonary Dysplasia After NICU Discharge: A Prospective Study of Parents and Clinical Stakeholders

Objective

Understand barriers and facilitators to follow-up care for infants with bronchopulmonary dysplasia (BPD).

Methods

Qualitative study of parents and clinical stakeholders caring for infants with BPD. The interview guide was developed by a mother of a former 23-week preterm infant, neonatologist, pulmonologist, nurse, and qualitative researcher. Purposive sampling obtained a heterogenous sociodemographic and professional cohort. Subjects discussed their experience with BPD, barriers to care, caregiver quality of life and health education. Interviews were audio-recorded, transcribed and coded. Thematic analysis was used.

Results

Eighteen parents and 20 stakeholders completed interviews. Family-level themes included pragmatic barriers like transportation being multi-faceted; and caregiving demands straining mental health. System-level themes included caregiver education needing to balance process needs with future trajectories; and integration of primary care, specialty care, and community supports.

Conclusions

Individual and system barriers impact follow-up for infants with BPD. This conceptual framework can be used to measure and improve care.

A Family-Based Mental Health Navigator Intervention for Youth in the Child Welfare System: Protocol for a Randomized Controlled Trial

BACKGROUND

Youth in the child welfare system (child welfare-involved [CWI] youth) have high documented rates of mental health symptoms and experience significant disparities in mental health care services access and engagement. Adolescence is a developmental stage that confers increased likelihood of experiencing mental health symptoms and the emergence of disorders that can persist into adulthood. Despite a high documented need for evidence-based mental health services for CWI youth, coordination between child welfare and mental health service systems to increase access to care remains inadequate, and engagement in mental health services is low. Navigator models developed in the health care field to address challenges of service access, fragmentation, and continuity that affect the quality of care provide a promising approach to increase linkage to, and engagement in, mental health services for CWI youth. However, at present, there is no empirically supported mental health navigator model to address the unique and complex mental health needs of CWI youth and their families.

OBJECTIVE

Using a randomized controlled trial, this study aims to develop and test a foster care family navigator (FCFN) model to improve mental health service outcomes for CWI adolescents (aged 12-17 years).

METHODS

The navigator model leverages an in-person navigator and use of adjunctive digital health technology to engage with, and improve, care coordination, tracking, and monitoring of mental health service needs for CWI youth and families. In total, 80 caregiver-youth dyads will be randomized to receive either the FCFN intervention or standard of care (clinical case management services): 40 (50%) to FCFN and 40 (50%) to control. Qualitative exit interviews will inform the feasibility and acceptability of the services received during the 6-month period. The primary trial outcomes are mental health treatment initiation and engagement. Other pre- and postservice outcomes, such as proportion screened and time to screening, will also be evaluated. We hypothesize that youth receiving the FCFN intervention will have higher rates of mental health treatment initiation and engagement than youth receiving standard of care.

RESULTS

We propose enrollment of 80 dyads by March 2024, final data collection by September 2024, and the publication of main findings in March 2025. After final data analysis and writing of the results, the resulting manuscripts will be submitted to journals for dissemination.

CONCLUSIONS

This study will be the first to produce empirically driven conclusions and recommendations for implementing a family mental health navigation model for CWI youth with long-standing and unaddressed disparities in behavioral health services access. The study findings have potential to have large-scale trial applicability and be feasible and acceptable for eventual system implementation and adoption.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04506437; https://www.clinicaltrials.gov/study/NCT04506437.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49999.

Identifying barriers to obstructive sleep-disordered breathing care: Parental perspectives

OBJECTIVE

Despite established clinical practice guidelines for pediatric obstructive sleep-disordered breathing (SDB), disparities persist for this common condition. Few studies have investigated parental experiences about challenges faced in obtaining SDB evaluation and tonsillectomy for their children. To better understand parent-perceived barriers to treatment of childhood SDB, we administered a survey to assess parental knowledge of this condition.

MATERIALS & METHODS

A cross-sectional survey was designed to be completed by parents of children diagnosed with SDB. Two validated surveys were administered: 1) Barriers to Care Questionnaire and 2) Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents. Logistic regression modeling was performed to assess for predictors of parental barriers to SDB care and knowledge.

RESULTS

Eighty parents completed the survey. Mean patient age was 7.4 ± 4.6 years, and 48 (60%) patients were male. The survey response rate was 51%. Patient racial/ethnic categories included 48 (60.0%) non-Hispanic White, 18 (22.5%) non-Hispanic Black, and 14 (17.5%) Other. Parents reported challenges in the 'Pragmatic' domain, including appointment availability and cost of healthcare, as the most frequently described barrier to care. Adjusting for age, sex, race, and education, parents in the middle-income bracket ($26,500 - $79,500) had higher odds of reporting greater barriers to care than parents in the highest (>$79,500) income tier (OR 5.536, 95% CI 1.312-23.359, P = 0.020) and lowest income tier (<$26,500) (OR 3.920, 95% CI 1.096-14.020). Parents whose children had tonsillectomy (n = 40) answered only a mean 55.7% ± 13.3% of questions correctly on the knowledge scale.

CONCLUSION

Pragmatic challenges were the most encountered barrier that parents reported in accessing SDB care. Families in the middle-income tier experienced the greatest barriers to SDB care compared to lower and higher income families. In general, parental knowledge of SDB and tonsillectomy was relatively low. These findings represent potential areas of improvement to target interventions to promote equitable care for SDB.

Perceived benefits of cochlear implants by parents: expectations, decision-making process, and barriers to care

BACKGROUND

Identifying predictive factors of the cochlear implant outcomes in pediatric patients is critical in guiding tailored rehabilitation programs. The study aimed to assess cochlear implant outcomes, identify predictors, and highlight decision-making factors and barriers to quality care.

METHODS

This cross-sectional study included parents of children who received unilateral cochlear implants for bilateral severe- to- deep sensorineural hearing loss. Inclusion criteria were age ≤ 5 years and intelligence quotient (IQ) Scores ≥ 85, A pre-designed structured questionnaire was used to collect data from parents/guardians of the children attending follow-up. The Arabic validated Glasgow Children Benefit Inventory score was used to assess the health-related quality of life (QOL) after intervention.

RESULTS

The quality of life (QOL) score (outcome) after surgery was positive in all cases. Multivariate analysis showed that the site of operation (Bahtim hospital and Ain Shams Hospital [AOR(95% confidence interval CI), 5.7 (1.4-23), 5 (1.4-17.9), p = 0.015, 0.013, respectively]), education of the father (university/postgraduate [AOR (95% CI): 5 (1.4-17.9), p = 0.013]), the parents' expectation that their child would be able to participate in regular classroom activities [AOR (95% CI): 8.9 (3.7-21.3), p < 0.001], and history of Attention deficit/hyperactivity disorder (ADHD), perinatal hypoxia, and low birth weight [AOR (95% CI): 2.5 (1.2-5.1), 3.7 (1.7-8.1), 4.7 (2.1-10.5), p = 0.013, 0.001, ≤ 0.001, respectively] are significant independent predictors of good outcome.

CONCLUSION

All parents expressed a positive change in their child's QOL. Almost all parents of children with cochlear implants face many barriers in obtaining quality healthcare services for their children. Parents, especially those with lower schooling, should receive good counselling to increase their confidence in their children's capabilities and maximize benefits of regular follow-up. Improving the quality of healthcare centers is recommended.

Association of Patient Factors and Follow-Up in an International Volunteer Cleft Lip and Palate Repair Clinic in El Salvador

BACKGROUND

In countries which lack robust health care systems, congenital conditions such as cleft lip and/or palate deformities are often untreated in certain individuals. Many volunteer organizations have stepped in to fill this gap but certain factors, such as continuity of care, are yet to be studied for these clinics.

METHODS

This is a retrospective cohort study of 167 pediatric patients with cleft lip and/or palate residing in El Salvador treated by a nongovernmental organizations between 2011 and 2020. This data was used in univariate and multivariable models to associate particular patient factors to their likelihood of following up to their annual clinic visits.

RESULTS

Each 1-year increase in duration of follow-up was associated with a 27% decrease in the odds of attending a visit. In addition, 33.7% of cleft lip and 49.7% of cleft palate/cleft lip and palate patients returned at least once. Males had 36% higher odds of attending a return visit compared with females but this difference was not statistically significant. Time spent travelling to the clinic had no effect on follow-up rates.

CONCLUSION

Nongovernmental organizations utilizing a diagonal care model should consider using more strategies to maximize continuity of care by increasing communication with patients and emphasizing the need of following up during clinic visits. Continued and increased collaboration with the local team is also of great importance.

Diagnostic Delay in Paediatric Inflammatory Bowel Disease-A Systematic Investigation

Diagnostic delays (time from the first symptoms to diagnosis) are common in inflammatory bowel disease (IBD) and may lead to worse disease progression and treatment outcomes. This study aimed to determine the duration of diagnostic delays (DD) and to explore associated factors in a cohort of children with IBD in New Zealand. In this study, patients with IBD diagnosed as children and their parents/caregivers completed questionnaires on the patients’ medical history, diagnostic experience, and demographic characteristics. The parent/caregiver questionnaire also included the Barriers to Care Questionnaire (BCQ). Patients’ healthcare data was reviewed to summarise the history of clinical visits and determine symptoms. Total DD, healthcare DD, patient DD and parent DD were derived from the primary dataset. Factors associated with the different types of DD were explored with a series of simple linear and logistical ordinal regressions. A total of 36 patients (Crohn’s disease 25, ulcerative colitis 10; male 17) were included. They were diagnosed at a median age of 12 years (interquartile range (IQR) 10−15 years). Total healthcare delay (from first healthcare visit to formal diagnosis) was median (IQR) 15.4 (6.5−34.2) months. The median (IQR) specialist-associated delay was 4.5 (0−34) days. Higher household income was associated with shorter healthcare delay (p < 0.018), while lower overall BCQ scores (indicating more barriers experienced) were associated with longer total healthcare DD. Higher scores in each subscale of BCQ (Skills; Pragmatics; Expectations; Marginalization; Knowledge and Beliefs) were also significantly associated with shorter total healthcare delay (p < 0.04). This study found substantial diagnostic delays in paediatric patients with IBD and identified significant associations between longer total healthcare diagnostic delays and overall household income and higher self-reported barriers to accessing healthcare.

Caregiver experiences with accessing sickle cell care and the use of telemedicine

BACKGROUND

Sickle cell disease (SCD) is associated with a wide range of complications. However, a multitude of barriers prevent SCD patients from receiving adequate healthcare, including difficulties with transportation and lack of provider knowledge about disease sequelae. Importantly, studies have demonstrated the benefits of telemedicine in addressing barriers to healthcare. While previous studies have identified barriers to care through quantitative methods, few studies have explored barriers which affect the pediatric SCD patient population in the Midwest, wherein the geographical landscape can prohibit healthcare access. Furthermore, few studies have established acceptability of telemedicine among caregivers and patients with SCD.

METHODS

This study aims to increase understanding of barriers to care and perceptions of telemedicine by caregivers of pediatric SCD patients in a medically under-resourced area in the Midwest. Researchers conducted semi-structured interviews with caregivers of children with SCD. The interviews were audio-recorded and transcribed. Thematic analyses were performed.

RESULTS

Researchers interviewed 16 caregivers of 15 children with SCD. Thematic analyses of the interview transcripts revealed four broad themes regarding caregiver burden/stress, both facilitators and barriers to SCD healthcare, and general thoughts on the acceptability/usefulness of telemedicine.

CONCLUSION

This qualitative study describes common burdens faced by caregivers of SCD, barriers to and facilitators of SCD care in the Midwest, and caregiver perceptions of the usefulness and efficacy of telemedicine for SCD care.

Barriers to the access and utilization of healthcare for trafficked youth in the United States

BACKGROUND

Child trafficking is a pervasive public health problem in the United States, with significant health consequences for survivors. Previous studies demonstrated that survivors face barriers to healthcare, though much of the literature has not solely focused on domestic child trafficking.

OBJECTIVE

To identify barriers to healthcare faced by survivors of child trafficking in the United States, and to characterize the landscape of available trauma-informed medical services.

PARTICIPANTS

62 adult survivors of child trafficking (83% female, 10% male, 7% transgender; 90% sex trafficking, 25% labor trafficking; median age of entry 16) and 37 community agency professionals who work with trafficked children.

SETTING

The United States of America.

METHODS

The Barriers to Care Questionnaire (BCQ) was adapted, piloted with a focus group, and disseminated to participants.

RESULTS

A statistically significant increase in survivors seeking healthcare after compared to before trafficking was demonstrated (p < 0.05). Eighteen consequential barriers to healthcare were identified. The marginalization domain, representing the individual's perception of negative experiences with the healthcare system, had the highest number of consequential barriers. The majority of survivor and agency participants felt the physical and mental health needs of survivors are not being met, but would seek out trauma-informed healthcare if it were available in their community.

CONCLUSIONS

Survivors of child trafficking in the U.S. experience a wide range of barriers to healthcare, and a lack of available trauma-informed healthcare. This study identified barriers to healthcare that can be considered by providers hoping to provide accessible and truama-informed services to trafficked children.

Disparities in Access to Pediatric Otolaryngology Care During the COVID-19 Pandemic

OBJECTIVE

Racial/ethnic minority pediatric otolaryngology patients experience health disparities, including barriers to accessing health care. Our hypothesis for this study is that Hispanic or economically disadvantaged patients would represent a larger percentage of missed appointments and report more barriers to receiving care during the COVID-19 pandemic.

METHODS

A cross-sectional survey utilizing a modified version of the Barriers to Care Questionnaire was administered via telephone to no-show patients, and median income by zip code was collected. Chi-squared, logistic regression, and Student's t-tests were used to investigate any differences in those who did and did not keep their appointments as well as any differences in mean questionnaire scores.

RESULTS

No-show patients were more likely to be Hispanic than not (OR 2.3, 95% CI: 1.3, 3.9, P = .002) and to live in a zip code that had a median income less than 200% of the federal poverty level (OR 1.7, 95% CI: 1.2, 2.4, P = .004). Respondents with a high school degree tended to report more barriers to care compared to those with less education.

CONCLUSION

In our study, we identified ethnic, financial, and logistic concerns that may contribute to patients failing to keep their appointments with the otolaryngology clinic. Future studies are needed to assess the efficacy of measures aimed to reduce these barriers to care such as preventive plans to assist new patients and expanding telehealth services.

Access Differentials in Primary Healthcare among Vulnerable Populations in a Health Insurance Setting in Kumasi Metropolis, Ghana: A Cross-Sectional Study

Background. Access to healthcare remains a challenge towards the achievement of the Sustainable Development Goals in Ghana. There still remain inequalities in the distribution of health services especially among vulnerable groups despite sustained efforts to strengthen the health system. This study was conducted to analyze access differentials among different vulnerable groups in the context of primary healthcare under a National Health Insurance Scheme (NHIS) in Ghana. Methods. This study was a descriptive cross-sectional study conducted among multilevel participants of vulnerable groups in Kumasi Metropolis: 710 vulnerable people constituting elderly/aged (n = 359), pregnant women (n = 117), head poters (teenage girls who migrated from the northern Ghana mainly to the capital cities of the Ashanti and Greater Accra region to help in carrying of goods for their livelihood) (n = 86), sex workers (n = 75), and other vulnerable groups (people with disabilities and street participants) (n = 73). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to access the association between vulnerability and access to healthcare. Results. Close to a fifth, 18.5% of the study respondents were unable to access care at any point in time during the last 12 months. Reasons for the inability to access healthcare included limited funding (69.7%), poor attitude of service providers (7.6%), distance to health centers (8.3%), and religious reasons (6.2%). More than 95% of respondents were insured under the NHIS, but acceptability of service provision under the NHIS was low among the vulnerable groups. In the crude models, pregnant women had lower prevalence of access to medications as compared to the elderly (prevalence ratio (PR): 0.88; 95% CI: 0.80–0.98). Head poters and other vulnerable groups were also less likely to view healthcare as affordable as compared to the elderly. The differences in healthcare access observed were attenuated after adjustment for sociodemographic characteristics and healthcare-related factors. Conclusions. Despite the introduction of a NHIS in Ghana, this study highlights challenges in healthcare access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to work to address access differentials in the NHIS and adopt other innovative care strategies that may have broader applicability for all populations.

Barriers to Dental Care in Individuals with Special Healthcare Needs in Qatif, Saudi Arabia: A Caregiver's Perspective

OBJECTIVE

Access to dental care is a key factor influencing oral health outcomes. Individuals with special healthcare needs are at risk of not having access to dental care services which they need to maintain their oral health. This study assessed the magnitude of this problem and identified barriers responsible for the difficulties in accessing dental care in Qatif, Saudi Arabia, as reported by caregivers of individuals with special healthcare needs.

METHODS

This cross-sectional study collected data using a self-administered survey questionnaire from caregivers of individuals with special healthcare needs across 11 centers (eight special needs centers and three schools) in Qatif, Eastern Province of Saudi Arabia, between February and April 2019.

RESULTS

A total of 186 caregivers participated in the study, 102 (54.8%) of whom reported difficulties in getting access to dental care. The key barriers included lack of time on the part of caregivers (60.8%), unsuitable clinic environment (53.9%), difficulties with transportation (51.9%), medical/health status of the individual with special healthcare needs (51.0%), and geographically distant dental clinics (51.0%). Caregiver demographics (age, gender, and educational level) had no significant influence on the difficulties reported by caregivers in getting access to dental care for individuals with special healthcare needs (p>0.05).

CONCLUSION

A large proportion of caregivers in Qatif, Saudi Arabia, experience difficulties with access to dental care services for individuals with special healthcare needs. The most common barriers are physical accessibility of dental facilities (for individuals with special healthcare needs), affordability, and lack of skills and knowledge of dental care providers.

Sickle cell disease in Grenada: Quality of life and barriers to care

BACKGROUND

Grenada is a small, resource-limited Caribbean country with a high incidence of sickle cell disease (SCD). Since little is known about the challenges facing individuals living with SCD in the West Indies, we sought to assess barriers to healthcare and the impact of SCD on quality of life in Grenada.

METHODS

Both adults aged 18+ (n = 19) and caregivers of children aged 2-17 (n = 26) completed validated survey measures regarding barriers to care and quality of life, along with a genetics knowledge questionnaire. Caregivers also completed a caregiver burden scale. Survey scores were calculated, and responses were analyzed for an association between demographic variables.

RESULTS

The Barriers to Care Questionnaire, in which lower scores indicate more barriers, revealed that both adults (mean = 69.9) and children (mean = 75.5) with SCD experienced reduced access to care. The Adult Sickle Cell Quality of Life Measurement Information System indicated increased depression and loneliness in adults, with the lowest scores in the Emotional subscale. However, the Pediatric Quality of Life Inventory answered by caregivers of children with SCD showed the lowest scores in the Physical Functioning subscale. Further analysis using the Caregiver Burden Scale-Zarit Burden Interview revealed that 53.8% of caregivers of children with SCD indicated "little to no burden," which may reflect a difference in cultural expectations of a caregiver between high-income countries and Grenada. Finally, ~80% of respondents knew that SCD was a genetic condition; however, 61%-84% could not correctly indicate recurrence risks, demonstrating a need for additional education.

CONCLUSION

These data provide new insights regarding the experience of living with SCD in Grenada and support the need for further investigations into specific barriers to healthcare delivery, which could also improve education and well-being for those affected by SCD in Grenada and in the broader Caribbean community.

A Qualitative Analysis of Factors Impacting Comprehensive Cleft Lip and Palate Care in Ghana

OBJECTIVE

The objective of this study was to examine practices regarding cleft lip and palate (CLP) among medical professionals and caregivers of children with CLP and to identify barriers and facilitators to comprehensive CLP care at a hospital in West Africa.

DESIGN

Qualitative methods used consisted of individual semistructured interviews with caregivers of children with CLP and one focus group with CLP team members.

SETTING

A majority of the interviews took place in the hospital, with some occurring during home visits. The focus group was conducted in the same hospital.

PARTICIPANTS

Forty-five caregivers of children with CLP and 1 adult with CLP completed an interview. Additionally, 2 of the caregivers had CLP and completed an interview from their perspective. The focus group consisted of 13 CLP team members from a comprehensive CLP team in Ghana.

INTERVENTIONS

Interviews consisted of semistructured, open-ended questions, and the focus group relied on a discussion guide. Line-by-line coding was used to identify common themes regarding barriers and facilitators to CLP care.

RESULTS

Barriers to CLP care that were consistent across caregiver interviews and the focus group were lack of knowledge regarding CLP, stigma and cultural beliefs surrounding CLP, transportation, financial, and feeding/nutrition issues. Barriers to care identified in the interviews and focus group were similar; however, facilitators to care varied greatly between the 2.

CONCLUSIONS

Two different qualitative methods provided unique perspectives on barriers and facilitators to CLP care. However, patients and caregivers continue to face substantial barriers to obtaining care.

Impact of a natural disaster on access to care and biopsychosocial outcomes among Hispanic/Latino cancer survivors

Cancer is the leading cause of death in Puerto Rico (PR). Hurricane Maria (HM) and its aftermath lead to widespread devastation on the island, including the collapse of the healthcare system. Medically fragile populations, such as cancer survivors, were significantly affected. The goal of this study was to assess the impact of HM on barriers to care, emotional distress, and inflammatory biomarkers among cancer survivors in PR. This exploratory longitudinal study was conducted in health care facilities and community support groups from PR. Cancer survivors (n = 50) and non-cancer participants (n = 50) completed psychosocial questionnaires and provided blood samples that were used to assess inflammatory cytokines levels. Among this cohort, we identified 41 matched cancer survivors/non-cancer participants pairs. Data were analyzed through descriptive, frequencies, correlational, and regression analyses. Cancer survivors that were affected by HM reported increased barriers in accessing medical care, which were directly associated with anxiety, perceived stress, and post-traumatic symptomatology. Moreover, being a cancer survivor, predicted more barriers to receiving health care, especially in the first six weeks after the event, after which the effect was attenuated. Several inflammatory cytokines, such as CD31, BDNF, TFF3, Serpin E-1, VCAM-1, Vitamin D BP, and PDGF-AA, were significantly upregulated in cancer survivors while MMP9 and Osteopontin both had significant positive correlations with barriers to care. HM significantly impacted Puerto Ricans psychosocial well-being. Cancer survivors had significant barriers to care and showed increased serum inflammatory cytokines but did not show differences in anxiety, stress, and post-traumatic symptoms compared to non-cancer participants.

A study protocol for a randomized controlled trial of family-partnered delirium prevention, detection, and management in critically ill adults: the ACTIVATE study

Background

Delirium is very common in critically ill patients admitted to the intensive care unit (ICU) and results in negative long-term outcomes. Family members are also at risk of long-term complications, including depression and anxiety. Family members are frequently at the bedside and want to be engaged; they know the patient best and may notice subtle changes prior to the care team. By engaging family members in delirium care, we may be able to improve both patient and family outcomes by identifying delirium sooner and capacitating family members in care.

Methods

The primary aim of this study is to determine the effect of family-administered delirium prevention, detection, and management in critically ill patients on family member symptoms of depression and anxiety, compared to usual care. One-hundred and ninety-eight patient-family dyads will be recruited from four medical-surgical ICUs in Calgary, Canada. Dyads will be randomized 1:1 to the intervention or control group. The intervention consists of family-partnered delirium prevention, detection, and management, while the control group will receive usual care. Delirium, depression, and anxiety will be measured using validated tools, and participants will be followed for 1- and 3-months post-ICU discharge. All analyses will be intention-to-treat and adjusted for pre-identified covariates. Ethical approval has been granted by the University of Calgary Conjoint Health Research Ethics Board (REB19–1000) and the trial registered. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

Discussion

Critically ill patients are frequently unable to participate in their own care, and partnering with their family members is particularly important for improving experiences and outcomes of care for both patients and families.

Trial registration

Registered September 23, 2019 on Clinicaltrials.gov NCT04099472.

Identifying Modifiable Health Care Barriers to Improve Health Equity for Hospitalized Children

BACKGROUND

Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention.

METHODS

We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income).

RESULTS

Of eligible families, 61% (n = 3651) completed the admission survey; of those, 48% (n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted β = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (β = 3.82; 95% CI 3.22 to 4.43), cultural distance (β = 1.75; 95% CI 1.36 to 2.15), and marginalization (β = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers.

CONCLUSIONS

System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children.

Barriers to Healthcare for People Who Inject Drugs: A Survey at a Syringe Exchange Program

Objective: Despite research demonstrating increased need for healthcare services among people who use drugs, few studies have investigated barriers to general healthcare in this population. We explored the most common barriers to general healthcare faced by clients utilizing syringe access services. Methods: Clients of Project Safe Point- a syringe access service serving Albany, NY and surrounding regions-were surveyed on their general health practices and specific health care barriers. Descriptive analyses were used to identify which barriers were most prevalent. Results: Of the clients surveyed (n = 59), the most common specific barriers were deprioritization of medical care (i.e., procrastination [80%], finding it easier to ignore the problem [63%]), cost (i.e., not having insurance [59%], not being able to afford the cost of care [58%]), transportation (53%), and judgement by clinicians (53%). When participants were asked to choose which was their biggest barrier to healthcare, judgement by clinicians was chosen more than twice as often as any other barrier. Conclusion: While people who inject drugs at a syringe access program often experience traditional barriers to healthcare (i.e., logistical barriers, procrastination), nearly a quarter of the clients reported feeling judged by clinicians as their most significant barrier. Future work in this field should explore interventions that motivate clients to seek care and that reduce stigma in healthcare interactions.

Factors associated with using alternative sources of primary care: a cross-sectional study

BACKGROUND

Mobile (MHCs), Community (CHCs), and School-based health clinics (SBHCs) are understudied alternative sources of health care delivery used to provide more accessible primary care to disenfranchised populations. However, providing access does not guarantee utilization. This study explored the utilization of these alternative sources of health care and assessed factors associated with residential segregation that may influence their utilization.

METHODS

A cross-sectional study design assessed the associations between travel distance, perceived quality of care, satisfaction-adjusted distance (SAD) and patient utilization of alternative health care clinics. Adults (n = 165), child caregivers (n = 124), and adult caregivers (n = 7) residing in New Orleans, Louisiana between 2014 and 2015 were conveniently sampled. Data were obtained via face-to face interviews using standardized questionnaires and geospatial data geocoded using GIS mapping tools. Multivariate regression models were used to predict alternative care utilization.

RESULTS

Overall 49.4% of respondents reported ever using a MCH, CHC, or SBHC. Travel distance was not significantly associated with using either MCH, CHC, or SBHC (OR = 0.91, 0.74-1.11 p > .05). Controlling for covariates, higher perceived quality of care (OR = 1.02, 1.01-1.04 p < .01) and lower SAD (OR = 0.81, 0.73-0.91 p < .01) were significantly associated with utilization.

CONCLUSIONS

Provision of primary care via alternative health clinics may overcome some barriers to care but have yet to be fully integrated as regular sources of care. Perceived quality and mixed-methods measures are useful indicators of access to care. Future health delivery research is needed to understand the multiple mechanisms by which residential segregation influences health-seeking behavior.

Parents' reports of barriers to care for pediatric otolaryngology patients

OBJECTIVE

To understand parent perceptions of types and severity of barriers to care within the pediatric otolaryngology patient population in WV.

STUDY DESIGN

Descriptive survey.

SETTING

University pediatric otolaryngology clinic, Morgantown, WV.

SUBJECTS AND METHODS

Subjects were caretakers of pediatric patients in clinic. Subjects were asked to complete the modified validated Barriers to Care Questionnaire (BCQ) and to provide some demographic details.Each BCQ question response was reported as a Mean Total Score (MTS), ranging from 0 (complete barrier) to 100 (no barrier) and they were grouped into 5 BTC subscales. Demographic question responses were used to establish subgroups. Data for subscale groups was compared across the demographic subgroups using non-parametric methods.

RESULTS

301 parents provided responses. The overall mean BTC was 91.59 (95% CI 90.12-93.05). The Expectations and Pragmatics subscales were the two greatest barriers at 88.56 and 90.80, respectively. 26.7% reported no barriers to care. No statistically significant association was found among subscale scores and demographic subgroups.

CONCLUSIONS

Parents of pediatric otolaryngology patients in WV demonstrate low expectations of the healthcare system. There are concerns about pragmatics that could create barriers. Our hope is to spur scientific interest in this understudied healthcare topic. Future studies should be conducted to identify association/causation and help establish a framework for addressing potential barriers to care in the pediatric population.

Taking Action on Asthma: Increasing Influenza Vaccination Rates in Pediatric Asthma Through Quality Improvement

INTRODUCTION

Through a QI Collaborative, a school-based health center (SBHC) program was tasked with identifying ways to decrease asthma mortality and promote national asthma guidelines with evidence-based interventions. Children with asthma are at increased risk for influenza complications such as pneumonia, hospitalization, and death. Flu vaccinations reduce these morbidities.

METHODS

Utilizing the Institute for Healthcare Improvement Framework, a clinical microsystems assessment and root cause analysis evaluated both enablers and barriers in improving flu vaccination rates in asthma students. Continuous quality improvement over three academic years with adaption of process efficiencies including asthma database tracking, flu vaccination rates, and asthma preventative visits was demonstrated.

RESULTS

The number of students with asthma who received their flu vaccination increased from 11% to 47%.

DISCUSSION

The SBHC program improved flu vaccination rates and targeted asthma preventative services. Additional successes included the adaptation of a vaccination campaign to 14 SBHCs, education on flu vaccination, and better electronic health record documentation of asthma severity.

Cardiac Denial and Expectations Associated With Depression in Adults With Congenital Heart Disease

Depression in adults with congenital heart disease is highly prevalent and strongly associated with adverse prognosis. Better management of risk factors for depression may improve clinical outcomes in this population. We conducted a single-site, cross-sectional study of 78 adults with congenital heart disease followed at Washington University School of Medicine. Data considered in the analyses included retrospectively obtained clinical information and patients' self-assessed psychosocial functioning and health status. To identify the clinical and psychosocial variables associated with depression, we built a stepwise multivariate model to measure the relative contribution of these variables to depression status. The prevalence of depression in our sample was 26%. Our model accounted for approximately 67% of the variability in depression scores. The final model consisted of the Cardiac Denial of Impact Scale, expectations domain of Barriers to Care, and the energy and social domains of the Rand 36-Item Short Form Health Survey. Clinical variables did not predict variability in depression scores. In conclusion, greater cardiac denial and negative expectations of the healthcare team were associated with increased depression symptoms in ACHD.

Caregiver-Reported Outcomes and Barriers to Care among Patients with Cleft Lip and Palate

BACKGROUND

For children with cleft lip and/or palate, access to care is vital for optimizing speech, appearance, and psychosocial outcomes. The authors posited that inadequate access to care negatively impacts outcomes in this population.

METHODS

Sixty caregivers of children with cleft lip and palate were surveyed to assess perceived barriers using the validated Barriers to Care questionnaire. The questionnaire includes 39 items divided into five subscales, with higher scores indicating fewer barriers. Caregiver-reported outcomes were assessed using the Cleft Evaluation Profile, which captures cleft-specific appearance- and speech-related outcomes. Higher scores correspond to less satisfactory outcomes. Desire for revision surgery was assessed as a binary outcome among caregivers. Multivariable regression was used to evaluate the relationship of barriers to care, caregiver-reported outcomes, and desire for revision, adjusting for clinical and demographic covariates.

RESULTS

Sixty percent of caregivers perceived barriers to care, and caregivers who reported poorer access to care described poorer cleft-related outcomes (r = 0.19, p = 0.024). Caregivers with poorer skills (r = 0.17, p = 0.037), expectations (r = 0.17, p = 0.045), and pragmatics (r = 0.18, p = 0.026) subscale scores were associated with worse Cleft Evaluation Profile scores. Barriers were also negatively associated with aesthetic item scores (r = 0.11, p = 0.025). Finally, caregivers reporting fewer barriers were 21.2 percent less likely to express interest in revision surgery.

CONCLUSIONS

Barriers to care were associated with poorer appearance-related outcomes and increased interest in revision among caregivers of cleft patients. Enhancing access to care is critical in order to effectively meet goals of care for these families.

Family Caregiver Marginalization is Associated With Decreased Primary and Subspecialty Asthma Care in Head Start Children

BACKGROUND

Urban minority children are at risk for poor asthma outcomes and might not receive appropriate primary or subspecialty care. We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma.

METHODS

The Barriers to Care Questionnaire (BCQ) is used to measure expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control using the Test for Respiratory and Asthma Control in Kids and these outcomes: PCP visits for asthma in the past 6 months, subspecialty care (allergist or pulmonologist) in the past 2 years, and ED visits in the past 3 months.

RESULTS

Three hundred ninety-five caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent (n = 236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (odds ratio [OR], 0.95; P = .014) and subspecialty visits (OR, 0.92; P = .019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR, 0.98; P = .027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes.

CONCLUSIONS

Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the health care system (marginalization). Clinicians who serve at-risk populations should be sensitive to families' past experiences and should consider designing interventions to target the most commonly reported barriers.

Contributors to disease-specific health knowledge in adults with congenital heart disease: A correlational study

OBJECTIVE

Growth in the adults with congenital heart disease (ACHD) population represents a challenge to the health care infrastructure. As patients with chronic disease are increasingly held accountable for their own care, contributors to disease-specific health knowledge, which are known to correlate with patients' participation in care, merit investigation to design patient-focused interventions.

DESIGN

We conducted a single-site, cross-sectional study of ACHD patients. Investigators retrospectively gathered clinical data as well as psychometric and health status assessments completed at the time of enrollment.

OUTCOME MEASURES

We investigated the impact of clinical and psychological variables on Leuven Knowledge Questionnaire for Congenital Heart Diseases health knowledge composite scores (HKCS). Variables with significant associations were considered in a stepwise multivariable regression model to determine which combination of variables jointly explained variability in HKCS.

RESULTS

Overall HKCS was associated with the number of prior cardiac surgeries (r = 0.273; 95% CI: 0.050-0.467; P = .016), perceived stress (r = 0.260; 95% CI: 0.033-0.458; P = .024), SF-36 emotional well-being (r = -0.251; 95% CI: -0.451, -0.024; P = .030), history of noncardiac surgery (P = .037), cirrhosis (P = .048), and presence of implantable cardioverter-defibrillator (P = .028). On multivariable modeling, only the number of cardiac surgeries was found to correlate with HKCS.

CONCLUSIONS

While univariate correlations were found between HCKS and several other clinical and psychological variables, only number of prior cardiac surgeries independently correlated with disease-specific health knowledge in ACHD patients. These results suggest that clinical and psychological variables are not impediments to disease-specific health knowledge.

What do patients want from their asthma care doctors?

One of the most important causes of asthma morbidity, hospital admissions, and death is non-adherence to prescribed therapy. It is generally assumed that adherence rates can be increased with asthma education, although well conducted studies have not always supported this assumption. Education can be achieved, or can fail, in many ways and no two patients have the same needs or perceived needs. In order to better understand what children with asthma and their parents or caregivers would desire as support from their physician providers, we conducted a survey of nearly 1000 parents of asthmatic children affiliated with the Asthma and Allergy Network. Most of those who responded wanted convenient access to their doctor, more time spent in office visits with greater attention paid to the patient, help in navigating insurance and prescription costs and paperwork, and a partnership in developing care plans. Although most patients were well insured for medical coverage (not a given in the USA), half were dissatisfied with their self-reported asthma control, many were concerned about medication side effects, 60% were not cared for by an asthma specialist, and nearly half did not have an asthma action plan. These results are consistent with data from other published studies and suggest that we still can do much more to meet the needs of children for whom we provide asthma care.

Clinical and Psychological Drivers of Perceived Health Status in Adults With Congenital Heart Disease

The factors having the greatest impact on self-reported health status in adults with congenital heart disease (ACHD) remain incompletely studied. We conducted a single-site, cross-sectional study of ACHD patients followed at the Center for ACHD at Washington University School of Medicine, including retrospectively gathered clinical data and psychometric and health status assessments completed at the time of enrollment. To identify primary drivers of perceived health status, we investigated the impact of the demographic, clinical, and psychological variables on self-reported health status as assessed using the Rand 36-Item Short Form Health Survey. Variables with significant associations within each domain were considered jointly in multivariable models constructed via stepwise selection. There was domain-specific heterogeneity in the variables having the greatest effect on self-reported health status. Depression was responsible for the greatest amount of variability in health status in all domains except physical functioning. In the physical functioning domain, depression remained responsible for 5% of total variability, the third most significant variable in the model. In every domain, depression more strongly influenced health status than did any cardiac-specific variable. In conclusion, depression was responsible for a significant amount of heterogeneity in all domains of self-perceived health status. Psychological variables were better predictors of health status than clinical variables.

Barriers to pediatric cochlear implantation: A parental survey

OBJECTIVE

This study aims to (1) determine barriers in the pediatric cochlear implantation process specific to publicly insured patients, wherein delayed implantation has been reported, and (2) compare the perceived barriers between publicly and privately insured patients.

SETTING

Tertiary care cochlear implantation center at academic pediatric hospital.

STUDY DESIGN

Cross-sectional survey, retrospective chart review.

METHODS

The validated, 39 item Barriers to Care Questionnaire was administered to the parents of 80 recipients of cochlear implantation by two surgeons between 2013 and 2016. Survey results and diagnosis to implant interval were compared based on public or private insurance status. Two-tailed Mann-Whitney and Fisher's exact test was used for statistical analysis.

RESULTS

Of 110 cochlear implants, 27 of 80 (34%) English-speaking parents completed the survey. 15 were privately insured and 12 were publicly insured. 23 of 27 respondents received cochlear implantation for pre-lingual sensorineural hearing loss. Publicly insured patients had significantly longer median time from diagnosis to implant than privately insured (19 vs. 8 mo, p = 0.01). The three worst scoring barrier categories for privately insured families in order were Pragmatics, Expectations, and Marginalization, whereas for publicly insured families it was Pragmatics, Skills, and Expectations. The worst scoring question for privately insured patients was "Having to take time off work". For the publicly insured, it was "Lack of communication."

CONCLUSION

Privately insured patients reported more barriers on the Barriers to Care Questionnaire than publicly insured patients did. Although pragmatics was the worst-scoring barrier category for both groups, difficulties found on the survey ranked differently for each group. This information can help providers address disparities and access barriers for vulnerable patients.

Behavioral health referrals in pediatric epilepsy

The purpose of this study was to examine the feasibility of a behavioral health referral protocol and barriers to behavioral health care in a pediatric epilepsy clinic. A sample of 93 youth with epilepsy ages 10-17 and caregivers completed behavioral health and seizure severity measures during a routine epilepsy clinic visit. Key findings are that 47 (50.5%) of the youth screened positive for a behavioral health referral, and 35 of these youth were referred for behavioral health services. However, only 20% made and presented for the behavioral health appointment. The most commonly cited barrier for accessing and utilizing behavioral health care was stigma related- a mental health label for the child. The significance of this study lies in the revelation that solely screening for and educating caregivers about behavioral health symptoms and providing behavioral health referral information is not an ideal model. Instead, stigma related barriers point to the necessity of continued integrated physical and behavioral health care within the pediatric epilepsy visit.

Barriers to care and quality of primary care services in children with sickle cell disease

AIMS

The aims of this study were: to (1) identify barriers to care in children with sickle cell disease; (2) examine the quality of primary care services received by these children and (3) examine the relationship between barriers to care and quality of primary care services in children with sickle cell disease.

BACKGROUND

Effective management in children with sickle cell disease requires early access to a comprehensive range of preventive screenings, urgent care treatments for vaso-occlusive pain crisis and ongoing prophylactic treatments.

DESIGN

A cross-sectional survey of parents of children with sickle cell disease was conducted between April-September 2011.

METHODS

Parents of children with sickle cell disease completed the Barriers to Care Questionnaire and Parent's Perceptions of Primary Care.

RESULTS

Parents of children with sickle cell disease (n = 38) reported health system barriers such as inability to contact doctors or clinics, extended wait times and inconvenient clinic hours. Some barriers were reported more frequently among children with concurrent sickle cell disease and asthma, compared with those children without a concurrent asthma condition. Parents who reported more barriers were least likely to perceive their care as accessible, comprehensive and coordinated.

CONCLUSIONS

Minimizing healthcare barriers may improve the quality of primary care services received by children with sickle cell disease and consequently prevent complications associated with sickle cell disease.

IMPLICATIONS FOR NURSING PRACTICE

Nurses and other care providers need to identify healthcare barriers, so that access, coordination, comprehensiveness and overall quality of primary care services may be improved in children with sickle cell disease.

Reliability and Validity of the Pediatric Quality of Life Inventory With Individuals With Intellectual and Developmental Disabilities

The Pediatric Quality of Life Inventory (PedsQL) measures health-related quality of life, a growing area of research, particularly among individuals with disabilities. This research is necessary to fully understand the varied needs of the population and, ultimately, ensure that those needs are being met. The current study assessed the reliability and validity of the PedsQL in individuals with intellectual and developmental disabilities, including individuals with autism spectrum disorder. Participants included 359 caregivers of children, youth, and young adults with IDD. Caregivers completed the PedsQL 4.0 Generic Core Scales questions regarding the individual's physical health and the Strengths and Difficulties Questionnaire. The PedsQL achieved excellent reliability across scales, and distinguished healthy individuals from those with chronic health conditions, as well as individuals with ASD from those without. Factor analysis confirmed a 5-factor model, with moderate to high criterion validity. The PedsQL shows sound psychometric properties and may be a useful tool to measure psychosocial functioning in this population.

Unmet Health Care Service Needs of Children With Disabilities in Penang, Malaysia

Information on unmet health care needs reveal problems that are related to unavailability and inaccessibility of services. The study objectives were to determine the prevalence, and the reasons for unmet service needs among children with disabilities in the state of Penang, Malaysia. Caregivers of children with disabilities aged 0 to 12 years registered with the Penang Social Welfare Department in 2012 answered a self-administered mailed questionnaire. A total of 305 questionnaires were available for analysis (response rate 37.9%). Services that were very much needed and yet highly unmet were dental services (49.6% needed, 59.9% unmet), dietary advice (30.9% needed, 63.3% unmet), speech therapy (56.9% needed, 56.8% unmet), psychology services (25.5% needed, 63.3% unmet), and communication aids (33.0% needed, 79.2% unmet). Access problems were mainly due to logistic issues and caregivers not knowing where to obtain services. Findings from this study can be used to inform strategies for service delivery and advocacy for children with disabilities in Penang, Malaysia.

Barriers in asthma care for pediatric patients in primary care

INTRODUCTION

There are many barriers to treating children with asthma. Barriers limit access with subsequent disturbances in quality outcomes. This study explored the difference in quality outcomes, utilization outcomes, parental knowledge, and barriers to care between children who had controlled versus uncontrolled asthma.

METHOD

Data were analyzed between two intact groups of caregivers of children with asthma. Caregivers in both groups completed the Asthma Knowledge Test and the Asthma Barrier Questionnaire.

RESULTS

Caregivers (n = 62) were primarily mothers (85.5%). Children with uncontrolled asthma missed 33.3% more days of school. The caregivers of the children with controlled asthma answered more questions on the Asthma Knowledge Test correctly and had a lower score on the Asthma Barrier Questionnaire.

DISCUSSION

Asthma control is essential. By identifying barriers to care, health care providers can build an action care plan to individualize each patient's needs.

Barriers to care for children with orofacial clefts in North Carolina

BACKGROUND

Little is known about the barriers faced by families of children with birth defects in obtaining healthcare. We examined reported perceived barriers to care and satisfaction with care among mothers of children with orofacial clefts.

METHODS

In 2006, a validated barriers to care mail/phone survey was administered in North Carolina to all resident mothers of children with orofacial clefts born between 2001 and 2004. Potential participants were identified using the North Carolina Birth Defects Monitoring Program, an active, state-wide, population-based birth defects registry. Five barriers to care subscales were examined: pragmatics, skills, marginalization, expectations, and knowledge/beliefs. Descriptive and bivariate analyses were conducted using chi-square and Fisher's exact tests. Results were stratified by cleft type and presence of other birth defects.

RESULTS

Of 475 eligible participants, 51.6% (n = 245) responded. The six most commonly reported perceived barriers to care were all part of the pragmatics subscale: having to take time off work (45.3%); long waits in the waiting rooms (37.6%); taking care of household responsibilities (29.7%); meeting other family members' needs (29.5%); waiting too many days for appointments (27.0%); and cost (25.0%). Most respondents (72.3%, 175/242) felt "very satisfied" with their child's cleft care.

CONCLUSION

Although most participants reported being satisfied with their child's care, many perceived barriers to care were identified. Due to the limited understanding and paucity of research on barriers to care for children with birth defects, including orofacial clefts, additional research on barriers to care and factors associated with them are needed.

Overview of qualitative research

Qualitative research methods are a robust tool for chaplaincy research questions. Similar to much of chaplaincy clinical care, qualitative research generally works with written texts, often transcriptions of individual interviews or focus group conversations and seeks to understand the meaning of experience in a study sample. This article describes three common methodologies: ethnography, grounded theory, and phenomenology. Issues to consider relating to the study sample, design, and analysis are discussed. Enhancing the validity of the data, as well reliability and ethical issues in qualitative research are described. Qualitative research is an accessible way for chaplains to contribute new knowledge about the sacred dimension of people's lived experience.

Prevalence of and disparities in barriers to care experienced by youth with type 1 diabetes

OBJECTIVE

To describe the prevalence of access and process barriers to health care and to examine their relationship to sociodemographic and disease factors in a large and diverse cohort of US youth with type 1 diabetes.

STUDY DESIGN

A cross-sectional analysis of 780 youth who participated in the SEARCH for Diabetes in Youth Study and were diagnosed with type 1 diabetes in 2002-2005. Experience of barriers to care was collected from parent report on questionnaires. Analyses included multivariate regression models to predict the presence of specific barriers to care.

RESULTS

Overall, 81.7% of participants reported at least one barrier; the 3 most common were costs (47.5%), communication (43.0%), and getting needed information (48.4%). Problems with access to care, not having a regular provider, and receiving contextual care (care that takes into account personal and family context) were associated with poorer glycated hemoglobin levels. Adjusted multivariate models indicated that barriers related to access (regular provider, cost) were most likely for youth with low family income and those without public health insurance. Barriers associated with the processes of quality care (contextual care, communication) were more likely for Hispanic youth and those whose parents had less education.

CONCLUSIONS

This study indicates that a large proportion of youth with type 1 diabetes experience substantial barriers to care. Barriers to access and those associated with processes of quality care differed by sociodemographic characteristics. Future investigators should expand knowledge of the systemic processes that lead to disparate outcomes for some youth with diabetes and assess potential solutions.

A systematic review of explanatory factors of barriers and facilitators to improving asthma management in South Asian children

BACKGROUND

South Asian children with asthma are less likely to receive prescriptions and more likely to suffer uncontrolled symptoms and acute asthma admissions compared with White British children. Understanding barriers are therefore vital in addressing health inequalities. We undertook a systematic review identifying explanatory factors for barriers and facilitators to asthma management in South Asian children. South Asians were defined as individuals of Indian, Pakistani or Bangladeshi descent.

METHODS

Data Sources - Medline, HMIC, EMBASE, ASSIA, Web of Science, BNI, CINAHL, PsycINFO, OpenSIGLE, CRD, Scopus, NHS Evidence, Cochrane Library, Campbell Collaboration, RCPCH, ATS, ERS, Asthma UK, Google Scholar & Asthma Guidelines (BTS, GINA, ATS, Monash, NAEPP, Singapore & New Zealand) to August 2013.Inclusion Criteria - Qualitative, quantitative or mixed methods research with primary focus on identifying explanations for barriers and/or facilitators to asthma management in South Asian children aged 0-18 years with diagnosed/suspected asthma and/or carers and/or healthcare professionals.Data Extraction - Three authors independently reviewed, selected & extracted eligible articles with disagreements resolved by research team discussion.

RESULTS

15 studies encompassing 25,755 children, 18,483 parents/carers and 239 healthcare professionals were included. Barriers and explanatory factors identified were:1. Lack of asthma knowledge in families and healthcare professionals.2. Under-use of preventer medications.3. Non-acceptance/denial of asthma.4. Over-reliance on Emergency Department management.5. Communication problems.6. Non-adherence to medication.7. Use of complementary therapies.Little facilitators regarding asthma management were identified.

CONCLUSIONS

Several key issues were identified as likely to be ethnic-specific to South Asian families, rather than a reflection of minority status: impact of parental and professional knowledge and beliefs, health service utilisation pattern explanations and the impact of prejudice and stigmatisation. Other explanations such as language barriers are not strictly ethnic specific but instead reflect a minority position.Further research is required to identify why barriers exist, the mechanisms by which they impact on asthma management and how they can be overcome. Furthermore, understanding the difference between barriers and explanations that are ethnic-specific and those that are related to being a minority will enable the application of generic system-wide interventions where ethnicity is not the issue and ethnically-tailored interventions where needed.

Perceived barriers to care in a pediatric medical home: the moderating role of caregiver minority status

OBJECTIVE

To examine the association of minority status to perceived barriers to care and health-related quality of life in families presenting to a Medical Home.

METHOD

Fifty-three caregivers were classified as minority or nonminority caregivers based on self-reported race/ethnicity. Caregivers completed a measure of perceived barriers to care and child health-related quality of life.

RESULTS

Minority caregivers reported more perceived barriers to care with regard to the pragmatics of obtaining health care. The association between perceived barriers to care and child health-related quality of life was moderated by minority status. Perceived barriers to care were only related to child health-related quality of life among minority caregivers.

CONCLUSION

Minority families may have difficulties with the cost of health care or logistics of obtaining health care for their child. Perceived health care barriers may still exist within pediatric Medical Homes for minority caregivers and affect child health-related quality of life.

The clinical utility of health-related quality of life screening in a pediatric inflammatory bowel disease clinic

BACKGROUND

Adjusting to symptom flares, treatment regimens, and side effects places youth with inflammatory bowel disease (IBD) at increased risk for emotional and behavioral problems and adverse disease outcomes. Implementation of psychosocial screening into clinical practice remains a challenge. This study examines the clinical utility of health-related quality of life (HRQOL) screening in predicting disease outcome and healthcare utilization.

METHODS

One hundred twelve youth of 7 to 18 years diagnosed with IBD and their parents. Youth completed standardized measures of HRQOL and depression. Parents completed a proxy report of HRQOL. Pediatric gastroenterologists provided the Physician Global Assessment. Families were recruited from a pediatric gastroenterology clinic. Retrospective chart reviews examined disease outcome and healthcare utilization for 12 months after baseline measurement.

RESULTS

Linear regressions, controlling for demographic and disease parameters, revealed that baseline measurement of youth and parent proxy-reported HRQOL predicted the number of IBD-related hospital admissions, gastroenterology clinic visits, emergency department visits, psychology clinic visits, telephone contacts, and pain management referrals over the next 12 months. Disease outcome was not significant.

CONCLUSIONS

Lower HRQOL was predictive of increased healthcare utilization among youth with IBD. Regular HRQOL screening may be the impetus to providing better case management and allocating resources based on ongoing care needs and costs. Proactive interventions focused on patients with poor HRQOL may be an efficient approach to saving on healthcare costs and resource utilization.

Factors associated with distance and time traveled to cleft and craniofacial care

BACKGROUND

Information on travel distance and time to care for children with birth defects is lacking. We examined factors associated with travel distance and time to cleft care among children with orofacial clefts.

METHODS

In 2006, a mail/phone survey was administered in English and Spanish to all resident mothers of children with orofacial clefts born 2001 to 2004 and identified by the North Carolina birth defects registry. We analyzed one-way travel distance and time and the extent to which taking a child to care was a problem. We used multivariable logistic regression to examine the association between selected sociodemographic factors and travel distance (≤60 miles and >60 miles) and time (≤60 min and >60 min) to cleft care.

RESULTS

Of 475 eligible participants, 51.6% (n = 245) responded. Of the respondents, 97.1% (n = 238) were the child's biological mother. Approximately 83% (n = 204) of respondents were non-Hispanic White; 33.3% (n = 81) were college educated; and 50.0% (n = 115) had private health insurance. One-way mean and median travel distances were 80 and 50 miles, respectively (range, 0-1058 miles). One-way mean and median travel times were 92 and 60 min, respectively (range, 5 min to 8 hr). After adjusting for selected sociodemographics, travel distance varied significantly by maternal education, child's age, and cleft type. Travel time varied significantly by child's age. Approximately 67% (n = 162) reported taking their child to receive care was not a problem.

CONCLUSION

Approximately 48% of respondents traveled > 1 hr to receive cleft care. Increasing access to care may be important for improving health outcomes among this population.

Barriers to mental health care: perceived delivery system differences

Treatment barriers have prompted the development of new models of care. Distance delivery systems bridge the access gap, increasing service availability. Understanding differences between systems can inform system improvements. Sixty participants from the Strongest Families telephone intervention for child behavior difficulties participated. Participants completed a questionnaire to explore differences in perceived treatment barriers (Treatment Barriers Index-TBI) and therapeutic processes (eg, therapeutic alliance, self-disclosure, health outcome) between face-to-face versus distance treatment. The TBI scale has strong internal reliability (Cronbach α: 0.95 [face-to-face]; 0.90 [distance]). Statistically significant differences were found between delivery system TBI mean scores, indicating fewer barriers with distance treatment. Therapeutic process differences between delivery modes suggest enhanced therapeutic alliance and self-disclosure scores with distance treatment. Increased access, convenience, and sense of privacy (visual anonymity) offered by a distance delivery system may provide an enhanced experience for some individuals.